This month’s Image Quiz from the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) highlights the case of a 34-year-old man who presented with a 1-month history of hand and wrist pain after driving his golf club into the ground during a swing. Anteroposterior (AP) and lateral radiographs of the wrist are shown, and findings from the physical exam are described.
The Image Quiz reviews the anatomy of the wrist, focusing on the symptoms and mechanisms of hamate injuries. The quiz question is: After standard AP and lateral radiographs, which imaging modality or view would be most helpful in arriving at a definitive diagnosis? Options for treating a fracture of the hook of the hamate are also discussed.
Here we are in the heart of Little League season, with an estimated 2.5 million kids out there playing. However, the rate of arm injuries in the 10- to 13-year-old population of baseball players has increased in the last two decades, despite the implementation of pitching guidelines.
In the May 4, 2016 edition of The Journal, Pennock et al. report findings from a prospective study of 26 Little League players whose elbows were physically examined and evaluated with MRI before the start of the season. Here are some salient results:
- Nine players (35%) had 12 positive MRI findings, including seven instances of edema of the medial epicondyle apophysis.
- Surprisingly, the prevalence of positive MRI findings and a history of arm pain were not greater in pitchers and catchers when compared to other position players.
- Those with a positive MRI finding had greater reduction in shoulder internal rotation compared with the nondominant arm.
- Year-round play (i.e., playing ≥8 months per year) and working with a private coach were associated with positive MRI findings and a history of elbow pain.
Noting that 27% of the players in this study used a private coach, Pennock et al. concluded that “ultimately, a balance must be found between teaching proper throwing mechanics and excessive throwing.” The authors also suggest that guidelines be revisited to address year-round play.
Each month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
In 1989, a group of sixty-seven asymptomatic individuals with no history of back pain or sciatica underwent magnetic resonance scans of the lumbar spine. In a landmark 1990 JBJS study, Boden et al. reported that three neuroradiologists who had no clinical knowledge of the patients interpreted the images as being substantially abnormal in 28% of the cohort (19 individuals). More specifically, a herniated nucleus pulposus was identified in 24 % of these asymptomatic subjects. These “magnetic-resonance positive” findings were more prevalent in older subjects; abnormal MRI findings were identified in 57% of those aged 60 to 80 years.
Boden et al. concluded that so many MRI findings of substantial abnormalities in asymptomatic people “emphasized the dangers of predicating a decision to operate on the basis of diagnostic tests—even when a state-of-the-art modality is used—without precise correlation with clinical signs and symptoms.”
However, despite the findings of Boden et al., during the last five years of the 1990s, Medicare claims showed a 40% increase in spine-surgery rates, a 70% increase in fusion-surgery rates, and a two-fold increase in use of spinal implants. Although spine-fusion surgery has a well-established role in treating certain spinal diseases, a 2007 systematic review of several randomized trials indicated that the benefits of fusion surgery were limited when treating degenerative lumbar discs with back pain alone. This review suggested the need for more thorough selection of surgical candidates, which was a caution also implied by Boden et al.
Although the three neuroradiologists in the Boden et al. study largely agreed on the absence or presence of abnormal findings on the MRIs, in 2014 Fu et al. reported on the interrater and intrarater agreements by four reviewers of MRI findings from the lumbar spine of 75 subjects. Even though this study used standardized evaluation criteria, there was significant variability in both interrater and intrarater agreement among the reviewers. As the Boden et al. study did 25 years ago, this study demonstrated the diagnostic limitations of MRI interpretation for lumbar spinal diseases.
In 2001, JBJS published a paper by Borenstein et al. that was a seven-year follow-up study among the same asymptomatic subjects studied by Boden et al. Borenstein et al. found that the original 1989 scans of the lumbar spine were not predictive of the future development or duration of low back pain. This led Borenstein et al. to conclude—as Boden et al. did—that “clinical correlation is essential to determine the importance of abnormalities on magnetic resonance images.”
Many important subsequent studies were inspired by the original findings of Boden et al. in JBJS. Most of them emphasize that for lumbar-spine diagnoses, an MRI is only one (albeit important) piece of data; that interpretation of MRIs is variable; and that all imaging information must be correlated to the specific patient’s clinical condition.
Several studies and national surveys indicate that approximately a quarter of US adults report having had back pain during the past 3 months, making this a common clinical complaint. But the findings of Boden, et al. and subsequent studies remind us that surgery is not always the appropriate treatment.
Daisuke Togawa, MD, PhD
JBJS Deputy Editor
What’s more important after rotator cuff repair: How the shoulder feels and functions or how it looks on an MRI or ultrasound?
Rotator cuff disease is the most common cause of shoulder pain and dysfunction. Operative repair is frequently performed with successful outcomes.
However, postoperative imaging studies reveal structural failures after such repairs in up to 90% of patients. The good news: many of those patients experience pain relief and improved function despite “failure.”
Two JBJS papers that shed new light on this and other rotator-cuff conundrums are the foci of this timely and insightful JBJS webinar:
Moderated by Andrew Green, MD, JBJS Deputy Editor for the Upper Extremity, this webinar will conclude with a live Q&A session, during which the audience can query the authors and commentators—and get answers—in real time.
Webinar attendees will hear from study authors Michael Khazzam, MD, and Jay D. Keener, MD. In addition, rotator cuff experts Scott Rodeo, MD, and Robert Tashjian, MD, will further analyze the findings from these studies and add perspectives from their own experience and research.
Register now to learn from this panel of experts and contribute to the dialogue—all from the convenience of your computer, smartphone, or tablet.
Moderator: Andrew Green, MD
Presenting authors: Jay D. Keener, MD, and Michael S. Khazzam, MD
Commentators: Scott Rodeo, MD, and Robert Tashjian, MD
Many orthopaedic surgeons come from an active background, often including competitive sports and other “high energy” activities. Injury is no stranger to many of us. In fact, it is often a youthful injury that put us in contact with an orthopaedic surgeon and spurred us to consider a career as a physician. Once we gain exposure to the various specialties in medical school rotations, we often find that orthopaedic surgeons are the most contented lot and have abundant enthusiasm for their patient-care activities… and we join the tribe.
Knee injury is common to many sporting activities, and of the various types of knee injuries, ACL rupture is among the most common. Many orthopaedists have experienced it firsthand. During my surgical education, ACL repair was in its infancy and we were navigating the transition between extra-articular and intra-articular reconstruction. Early in my academic career, I could identify many colleagues who had an ACL tear (diagnosed by physical exam with perhaps an arthrogram to check for meniscal tears, in those days prior to MRI) who had not undergone surgical reconstruction. This was my own personal situation. Now that the diagnosis is highly reliable and highly reproducible outpatient arthroscopic reconstruction is available, I suspect this is no longer the case. However, for patients who have lower functional expectations and demands in their future, nonoperative treatment should still be an option.
In the August 6, 2014 JBJS, Grindem et al. do the orthopaedic community a huge service by providing data from a prospectively enrolled and carefully followed cohort of 143 patients with ACL rupture who were treated both operatively and non-operatively. This study design carries all the limitations associated with any cohort study, with selection bias being a big factor. The findings that the 100 patients who selected reconstruction were younger and had expectations of higher-level sport activity are not surprising. This same surgically treated cohort was more likely to experience knee re-injury, probably due to increased exposure from level-I sports. The 43 nonsurgical patients returned to level-II sports in the first year much more quickly and in the second year were more likely to return to level-III sports than their surgically treated counterparts. In essence, there were no major differences between the two populations at two years in terms of knee extensor and flexor weakness. Those findings are no doubt highly correlated to patient factors such as rehabilitation compliance.
I conclude that there is still a role for non-operative management of ACL rupture in patients who select this route during a shared decision making process. We know that there seems to be a higher risk of subsequent meniscal injury in people without an ACL, but many patients are willing to accept this risk.
Donald Fithian tells us what he thinks of this study in an accompanying JBJS commentary. What do you think?
The medical landscape is always changing. With the Affordable Care Act, implementation of ICD-10, and penalties for not participating in the Physician Quality Reporting System (PQRS), practices have a lot of challenges ahead.
To help meet those challenges, orthopaedic surgeon Thomas C. Barber, chair of the AAOS Council on Advocacy, recommends that practices consider expanding ancillary services such as MRI or physical therapy. He also advises that practices should bill for all services rendered and use marketing and enhanced relationships with referring physicians to solidify their business. Finally, astutely observe the trends in your local health care community, such as ACO formation and changes in surgeon/hospital relationships. Barber says that understanding your practice’s economics and local environment will help you see opportunities for merging or collaborating with other practices.
Magnetic resonance imaging has revolutionized the field of orthopaedic diagnostics, but it has until now been limited by delivering largely static images. Researchers at the University of California, Davis have developed a new MRI technique called “active MRI” that can depict wrist joints in motion at an amazingly fast temporal resolution of 475 milliseconds. The advance could permit a patient to replicate a motion that causes pain while allowing a physician to “see inside” for the cause while the joint is moving.